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Pediatric Seizures Was that Seizure

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Pediatric Seizures Was that Seizure Powered By Docstoc
					I Almost Think I Can Remember
     Feeling a Little Different…

     Cam Brandt, RN, MS, CEN, CPN, CPEN
            Educator, Emergency Services
          Cook Children’s Medical Center
Objectives
Differentiate between the major categories of
seizures as defined by the ILAE

Discuss assessment principles used to categorize an
active seizure

Apply knowledge of seizures to selected case
studies
    Epidemiology
   Incidence
    › One in 100
    › Most likely in children or adults over 65
   Causes
    › 7 out of 10 cases have unknown cause
    › Congenital abnormalities
    › Birth asphyxia
    › Intrauterine infection
    › Head trauma
    › Brain tumors
    › Genetic factors
    › Serious illnesses (i.e. encephalitis, meningitis, parasitic
      infections)
    › Strokes
Glossary of Terms
   generalized seizure        partial seizure
    Discharge of cerebral       Initial activation of
    neurons affects the         neurons limited to a
    whole cerebral cortex       part of one cerebral
    from onset to               hemisphere. Great
    termination.                variation with clinical
                                expression and
                                severity.
                     Consciousness not impaired
Simple partial
                     Seizure activity in one part of the brain resulting in: a.) jerking in
                      one area of the body, arm, leg or face; b.) partial sensory seizures
                      where a patient experiences distorted environments, sensory
                      illusion or gastric discomfort. The motor or sensory activity may
                      progress to complex partial or generalized seizure.



                     Consciousness impaired
                     Seizure often starts with an aura, followed by random activity.
Complex partial




                      Person appears unaware of surroundings, seems dazed and
                      mumbles, is unresponsive, clumsy. Post-ictal confusion and lethargy
                      follows, often with a complaint of a headache, and the person has no
                      memory of what happened during the seizure.
Okay, It’s Not that Easy…
 Simple partial seizures
 Complex partial seizures
    › With impairment of consciousness at onset
    › Simple partial followed by impairment of
      consciousness
   Partial seizures evolving to generalized tonic-
    clonic (GTC) convulsions
    › Simple partial evolving into GTC
    › Complex partial evolving into GTC including those
      with simple partial onset
Managing Partial Seizures
 Children with this type of epilepsy need lots of
  reassurance -- and an adult who keeps track of
  how often the seizures occur.
 Keep hazards out of the way, reassure the child
  in a calm voice, and keep track of how long the
  seizure lasts.
 Prolonged confusion and clusters of complex
  partial seizures may require emergency
  treatment.
Specific Seizure Foci
  Do you remember your anatomy
      and physiology classes?
Temporal Lobe Focus
 Most common of partial seizures (nearly ½ of focal
  seizures and 30-35% of all epilepsies)
 Approximately 80-95% have auras
 Most have some type of automatism
    › Coordinated involuntary simple movements that the person
      is unaware of
         Lip smacking, lip pursing, chewing, swallowing
         Grunts or shrieks
         Fumbling or exploratory movements
         Ambulatory movements
         Aggressive behavioral acts
Auras
 By definition, a simple seizure
 Types
  › Epigastric aura
  › Fear or panic
  › Déjà vu or jamais vu
  › Auditory hallucinations
  › Olfactory and gustatory hallucinations
Frontal Lobe focus
 Approximately 30% of partial epilepsy
 Usually occur in clusters during sleep
 Abrupt onset and end with little or no
  postictal confusion
 Vocalizations include humming, screaming, or
  expletives
 Bizarre hysterical appearance
 Can be misdiagnosed as a psychiatric disorder
Parietal Epilepsy
 Simple focal
 Somatosensory seizures
  › Tingling, numbness, thermal, burning, tickling,
     pain
   › “Tingling around the left side of my lip, then it
     spreads to my left arm. Then I lose
     coordination and power in my arm. During this
     time, I am able to talk and understand.”
   › Face, hand and arm most likely to be affected
Occipital Epilepsy
  Only 5-10% of partial seizures
  Visual disturbances
   › Visual hallucinations: Brightly colored and
      circular, appearing in the periphery,
      becoming larger and multiplying
    › May have slight visual deterioration
    › Eyelid closures, fluttering, eyelid opening
  Consciousness not impaired
  May have ictal or postictal headache
Epileptic Spasm (infantile spasm)
   AKA West Syndrome
   Sudden flexion, extension (or combination of (usually)
    truncal and proximal muscles. Often occur in clusters.
   May be symmetrical or asymmetrical
   Eye deviation occur in 60%
   May have history of “reflux”
   Other symptoms:
    › Flexor spasm (“jack-knife spasm”)
    › Extensor spasm
    › Subtle spasms
       Yawning, gasping, facial grimacing, isolated eye movement,
        etc.
Psychogenic Non-Epileptic Seizures
(Pseudoseizures) in Children
 Hyperventilation    Body jolting
 Closed eyes         Shoulder
 Non-rhythmic         movements
  movements           Wrist movements
 Open mouth          Pelvic thrusting
                      Suggestive
Psychogenic Non-Epileptic Seizures
in Children
 Age start 8-10 yrs
 May be voluntary or involuntary
 Severe environmental stress
 Sexual or physical abuse (as high as 57%)
 May be seen after a real seizure for
  secondary gain
 Mood disorder
 Need psychiatric evaluation
Assessment: Your Role
 Were there any warning signs or was there an
  aura?
 Where did the seizure begin and how did it
  proceed?
 What type of movement was noted and what
  parts of the body were involved?
 Was there conjugate gaze deviation?
  Nystagmus? Were the eyes open or closed?
 What was the duration of the entire episode
  and of each phase?
Assessment, continued
 Was the patient conscious throughout the
  seizure? Did he respond to your questions?
  Appropriately?
 Was there urinary or bowel continence?
 What was the person’s behavior after the
  seizure?
 Was there any weakness or paralysis of the
  extremities?
 Were there any injuries noted?
 Did the patient sleep after the seizure?
Triage questions
 Known seizure patient:
   › Is he/she on AED’s? Did he miss a dose?
   › Fever or other illness?
   › Under stress or sleep deprived?
   › Do these seizures look typical?
   › Any OTC cold medications (esp. Benadryl)
 If not known
   › Other PMH (diabetes, asthma, reflux, renal
    disease, TBI)
Testing
 Questions (assess for    Physical
  30-45 seconds)             › Lift arms/legs
   › Name                    › Rub arms/legs/face
   › Close/open eyes         › Move head side-to-
   › Where are you?              side/up-and-down
   › Count                   ›   Stick out tongue
   › Repeat words (dog,      ›   Look to the
     cat, car)                   right/left/up/down
                             ›   Point to the
                                 ceiling/floor/mom/dad
                             ›   Touch your
                                 nose/head/belly
Emergency Care
 Primary Goal: Keep the Child Safe

 Lie the child flat, turn on their side if
  possible
 Remove harmful objects from the
  environment.
 Be calm, do not agitate the child.
 Do not try to restrain the child.
 If the child is safe, do not approach or
  confront if angry or agitated.
Abortive Medicines
 IV Ativan (0.1mg/kg/dose)
 Rectal Valium (Diastat AcuDial)
 If continued seizing and not
  stopped by above meds,
  consider:
  › IV Fosphenytoin (20mg/kg)
  › IV Phenobarbital (20mg/kg)

				
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